AGORAPHOBIA

Anxiety is a human trait and most individuals will have experience of
it. Anxiety helps with vigilance, learning and general performance but in excess,
it starts to work against us as extreme self-focus and apprehension reduces this attention and performance. Basically, people have then turned inward,
defending themselves from their anxiety and usually from life in general.
This means that instead of embracing activities as a challenge where things
are anticipated with pleasure and the person is open to new experience, many
activities come to be seen as a potential threat and are looked at with suspicion
and fearful anticipation; and life begins to close down.

Anxiety at the minor symptom level is familiar to virtually all of us
and from Anxiety Care's experience, this often seems to weigh against
an acute sufferer seeking help. Embarrassment and shame at an 'over
reaction', perhaps aggravated by the particular blending of emotions
(such as anger, shame, guilt or sadness mixing with a dominating fear) that
make up their 'personal anxiety' keeps the problem hidden and
prevents this person from understanding that their response doesn't
mean they are weak, soft or immature. It is often not understood that
anxiety can follow a continuum from mild to acute that leaves some people
with 'liveable' responses but others deeply disabled.

Agoraphobia

According to research, there are no particular personality differences
between agoraphobics and members of the general population. 'Fear
of fear' (fear of a panic attack) seems to be a component of the problem
but there are many other factors that lead to the avoidance central to the
disorder and not all agoraphobics experience panic attacks. People with
agoraphobia typically suffer from a 'cluster' of phobias.
Generally they will find it very difficult or impossible to carry out certain
activities. These could be going into crowded or public places, lifts, public
transport or simply anywhere away from home where 'escape' or
immediate access to help is not possible. They will probably also fear
standing in queues, going on bridges or sitting in any place where they feel
'trapped', such as at a hairdresser's or dentists.
A companion for outings is often sought and rapidly becomes essential.
There can also be additional fears, predominantly 'social' ones
such as a fear of blushing, trembling, talking eating or writing in front
of people and of being stared at. (These latter fears can also be part of
social phobia or separate specific phobias and don't necessarily mean
that someone suffering in this way is agoraphobic.) There may also be obsessional
and depressive symptoms. If the person becoming agoraphobic was significantly
depressed before onset, which is more common when the problem appears later
in life, this could be the disorder that is treated first.

The common belief that agoraphobics fear 'open spaces' is,
in general, untrue. So is the belief that a person must be totally incapable
of doing any of the things mentioned above - or be totally consistent in their
ability to do these things - before they can be designated agoraphobic. Many
agoraphobics are able to undertake certain activities under specific circumstances
or when the need is great. This falls into the category that anyone should
be able to understand when we make super-human efforts at times. For example,
the documented case of a woman who lifted a car off her child. Anyone
would understand that this was an incredible action fuelled by extreme need.
However, the agoraphobic might be in much the same situation when heavily pressed
to attend a family gathering or when faced with something that he or she desperately
wants to do. This is about 'balance': the weight of need
equalling the weight of ability and/or desire. Because an onlooker cannot
understand the particular balance involved, does not mean that the agoraphobic
can be written off as: 's/he can do it if s/he wants to!' The
contempt in this and the allied suspicion that the disability is not genuine
stops a lot of agoraphobics from trying new things when they feel 'strong' and
feeds in to a, possible, personal self-doubt and self-contempt. This
is never useful and actively works against an agoraphobic's recovery.

Onset of agoraphobia is usually between the ages of 18 and 35 and affects
between 1.5% and 3.5% of the general population. Onset can be sudden
or gradual, over weeks, months or even years; or it can come and go for a
considerable length of time before becoming a permanent problem. Severity
of symptoms can also vary enormously, with many people hiding their problem,
or just about coping, for many years. In some people, agoraphobia may 'come
and go' and there may be periods of years in between episodes where
there are virtually no symptoms. When someone develops Panic Disorder
(see the article on this site), agoraphobia often occurs too within the first
year. When there is severe panic with the agoraphobia, this may actually
maintain the disability even when other possible reasons for anxiety have
dwindled, and the person maintains a high fear of having more panic symptoms.
This would aggravate any anxiety condition.

Onset is often preceded by a large number of adverse life events in the
year or so before the condition is recognised (see: 'transitions'
on this site), but there is little evidence that a sudden trauma can cause
it. Once present for about a year, the condition may persist for decades
unless it is treated.

The Symptoms of Panic

Not all agoraphobics panic. In fact, many will experience little everyday
anxiety if they are able to avoid the situations they fear. Below are
the symptoms of panic found in Panic Disorder. Someone with less than
four of these would be defined as having agoraphobia without panic disorder.
The agoraphobic without panic disorder would still be afraid of the symptoms
that were seen as 'his' or 'hers', particularly if
it is thought they might lead to extreme embarrassment or danger like losing
bladder control or being left lying in the road. However the fear would
revolve around individual symptoms not fear of a full-blown panic attack.
If more than four of these symptoms have been experienced at any one time,
it is likely that the sufferer will be diagnosed as having Panic Disorder with
Agoraphobia. For the diagnosis of Panic Disorder alone, a person will have had
at least two spontaneous, 'out of the blue' panic attacks where
there are no fear-generating situations.

Treatments

There are a wide range of treatments available for anxiety disorders, from psychotherapy
to simple exposure work. The usual responses available on the NHS are
behavioural therapy and rational-emotive and cognitive-behavioural therapy.
Behaviourists tend to believe that our behaviour is learnt and that we are
a product of our environment. The behavioural approach usually involves
practicing more appropriate behaviour and reinforcing this by repetition and,
possibly, imitation. A good behavioural therapist will work out, with
the client, a plan for treatment and the goals to be reached by it. This will
almost certainly involve a series of practical steps as described below, for
becoming used to the anxiety generating situations (desensitising). It
might also include relaxation, anxiety self-management and practice with changing
habitual thought patterns (cognitive restructuring). Some therapists might include
a course of medication if symptoms are perceived by the client to be too overwhelming
to counter. However, many behaviourists subscribe to the view that the
anxiety must be faced 'head on' without chemicals between it and
the sufferer. So whether or not medication is involved will depend on
the therapist. From Anxiety Care's experience, sufferers need to
be in a state of mind where such practical work is viewed as viable if it is
to succeed. With long NHS waiting lists, the huge number of sufferers
and the lack of therapists, it is often pot-luck when such therapy is offered.
If this behavioural therapy is then available over a limited period and only
at a specific time and date,it would be also understandable if the therapy
centre involved accepted only those clients who appeared most likely to benefit
from it. And these might not be the clients most in need.

Rational-emotive and cognitive-behavioural therapies tend to work with
the client's thought patterns and the assumption that we are all able
to think rationally but may have become side-tracked into irrational pathways.
The therapist will help the client, much as a teacher would a student, to
look at their thinking and belief systems and to attempt to eliminate self-defeating
beliefs and attitudes. While it will probably be accepted that these
beliefs were mostly generated in childhood, the therapy will be based on current
difficulties and achieving a balance between what the client believes should be and what is, in reality, the reasonable option. The client
may also be encouraged to delve into, and express, personal feelings.
This is not analysis.

Many people coming to Anxiety Care believe that there is some fundamental
'thing' in their childhood that caused their disorder and that
once this is found, their problems will be over. Anxiety Care's
position is that virtually everyone could make a case for being emotionally
ill, or plain 'barking mad' on this basis, if they wanted to,
as it is not possible to go through childhood without some kind of damage.
Endlessly picking over this damage, great and small, might be interesting
but is unlikely to lead to recovery unless the current life is still heavily
linked in to this damage through a belief system. The idea that, once
this causing factor is found, cure is accomplished, just isn't true
and is more to do with a wish to be better rather than to go through the,
often painful, process of getting better.

Bearing in mind the huge need and the limited therapy time available, most people
with agoraphobia are going to have to organise their own structured recovery
programme. (See 'Self-treatment for Phobias' on this site). The practical steps would start with what could
just about be managed with some difficulty and work up to what is desired,
with as many steps in between as necessary. These steps can be very small and
practice needs to be undertaken for an hour or so a day, everyday, so that
the new behaviour can be reinforced in the mind.

Here are some steps that might help someone with agoraphobia who can make
it out into the street, but finds that the next step - walking to the local
shops - is too large to manage in one go. This big step, 'go to the
shops alone', has been broken down into a number of smaller ones:

Step 1: Walk with a helper as far
in the direction of the shops as you can manage
Step 2: Do the same, but walk further
Step 3: Continue the process until
you can actually reach the shops
Step 4: Walk to the shops with
the helper following 50 yards behind
Step 5: Walk to the shops with
the helper following 100 yards behind
Step 6: Walk to the shops with
the helper waiting there to meet you
Step 7: Walk to the shops alone.

Some Hints for Self-Exposure Work

When treating your phobia it is important to work out exactly what
the problem really is. If it is lifts, does their size, or their structure
(metal walls, open bars etc.), or how high they go make a difference?
If it is stairs, is it their width, something about the handrail, or the way
the stairs are built (for example, open or closed steps, whether you can see
through them etc.)? In the case of bridges, is it to do with the parapet? With
tall buildings, the windows? If you don't work out the real focus of your fears,
you could be wasting time trying to overcome the wrong problem. It is especially
important to do this for agoraphobia, so that you are clear exactly how many
different fears are involved in your condition.

The first step in the programme can be very simple - perhaps staying
in a situation that can just be managed now, but for a little longer than
before.

The steps can be as large or as small as necessary, and big steps can
be broken down into smaller ones. However, it is important to make sure that
each step challenges the anxiety a little more than the last.

Don't be overwhelmed by the size of the task. As a rule, the steps
become steadily easier as you work through them.

Don't expect to be completely free from anxiety before you leave each
step and go onto the next - it will go completely in its own time as you progress.

Do the exercises as often as you can. You are trying to build up positive
memories to replace all the bad ones of being beaten by the phobia, and too
long a gap between efforts makes this more difficult.

An hour or so at a time and repeating this every day is best. Waiting
until you feel 'strong' or until you cannot avoid it any longer
is not a positive approach.

Do enough at each step to raise your anxiety. You are trying to get
used to a level of physical symptoms that you can manage, and where you are
in control.

If it is possible to find someone to work with, who can talk to you
calmly and positively while you are doing the steps (not over-sympathising
or endlessly asking how bad you are feeling) this can help.

If you have a panic attack during your exposure work, try to remember
that the physical symptoms of panic will not do you any harm, and will always
ease off eventually, whether you run away from the situation or not. Many
people believe that a vague but terrible 'something' is going
to happen to them during a panic, and that they just manage to save themselves
in the nick of time by avoiding or escaping from the phobic situation. This
is not true.

Relaxation techniques can be helpful in tackling the next step, and
it is easy to practice relaxation in the privacy of your own home. If the
steps you have chosen prove impossible, of if you are depressed or have other
severe anxiety problems, then professional help from a clinical psychologist
or psychiatrist may be needed. You can reach such professionals through your
GP; and in any case we recommend that you contact your GP and talk to him or
her about your disorder.

Exposure Work and the Agoraphobic Cluster

Phobias tend to strike 'across the board', and grow to cover
many different situations in quick succession. However, the fear of these
different situations may need to be tackled one at a time. So, a person with
a fear of many different public places should not feel despondent if they
sort out their fear of the supermarket only to find that the hairdressers
or the church still cause a problem. It does not necessarily mean they will
have to plod through the same series of steps all over again with these other
situations. They will usually be able to start at a higher step level, and
will have the confidence of at least one practical success behind them.

Coping with Panic Attacks

Panic is the most extreme kind of anxiety reaction, and often becomes the experience
that people with agoraphobias fear most. It is the point where they become
absolutely convinced that something truly awful is about to happen to them
- and will happen, unless they can get away from it quickly. Typically, they
feel that they are about to lose control and do something horrible or humiliating
(such as defecating, urinating, screaming, running amok or having some kind
of 'fit'), or that they are going to go insane; or that they are
going to have a heart attack, stroke or brain haemorrhage.

Anxiety Care has looked most carefully into what happens during a panic
attack,and we can say with absolute confidence that:

we have never come across a single case of someone dying as a result
of a panic attack.

we have never come across a case of anyone 'going mad'
as a result of a panic attack.

Panic is an internal event. It may feel as if your mind and body are breaking
up, but the fact is that other people seldom notice, especially in busy places.
They are far too busy with their own affairs: if they see someone running
out of a shop, their first thought will not be "There goes one of those stupid
phobics". If they notice at all, they will assume you are late for something;
after five minutes they will have forgotten.

Genuine 'loss of control' is also very rare. Even in the very
small number of examples that we have come across, where the person claimed
to have lost all control, it wasn't really true. One person described
how she "rushed screaming out of the house" (but only after she had closed
the doors and windows). Another said she "kicked insanely at the car window
to get out" - but she had taken her shoes off first so as not to hurt herself
or damage the car. As for the fear of going berserk and attacking children
or mowing down passers-by, there are simply no records of a person in panic
ever having done such a thing.

Everyone who has had a panic attack (and this may include up to half the population)
realises that they have survived it unscathed. They may be shaken and drained
by the emotional stress of the experience, but panic attacks do not cause
permanent harm. What is more, panic attacks quickly subside, and this
is equally true if the person affected resists the urge to escape and stays
in the situation where the panic happened. But because escaping and the
reduction of the bodies responses happen at the same time, we 'learn',
incorrectly, that escaping is what causes them to do so. This is the
process that turns the anxiety into a phobia. In order to stop ourselves being
permanently on the run from fear itself, we need to 'unlearn'
this false logic. That means developing the strength NOT to run away when
a panic occurs.

Advice for Family and Friends

If you are with someone who is having - or has just had - a panic attack,
here are some points to bear in mind.

The most important thing is just to be there, and to be caring. Keep
calm yourself and don't start a cross-examination or over-react. Someone who
honestly feels they are about to die, or at the least pass out, does not want
to be interrogated with questions like "What on earth happened to you?", and
"What caused this?" Above all don't 'flap'. If you do, it will
only make things worse.

Too much concern can also make feelings of extreme fear even worse.
Don't say things like "Oh you poor thing!", "Oh dear, this is terrible", or
offer to call an ambulance. Families of agoraphobic people may unconsciously
help keep the problem alive by offering too much support.

Don't denigrate with comments like "Stop being so childish", or "Grow up
and snap out of it." A panic attack is no joke, and if the person affected
could just `snap out of it', they would have done so long ago.

Hyperventilation can be a problem. Hyperventilation means over
breathing; and over breathing means rapid, shallow breaths, rather than slow,
natural ones. We all breathe in oxygen and breathe out carbon dioxide,
but when over breathing, we breathe out too much carbon dioxide, leaving the blood
chemistry temporarily unbalanced. The net result is a sort of reduction
in 'pressure' which causes a constriction of some blood vessels
and a slight increase in the blood's alkaline level. This is not a dangerous
situation. The body soon compensates and retrieves the balance, but the
physical symptoms a person may experience while this is being done can be extremely
alarming.

One such symptom can be a painful contraction of muscles across the chest
which frequently results in the erroneous belief that a heart attack is imminent.
Other symptoms include tingling in hands and feet, abnormally rapid heart
beat, dizziness, disturbance in vision, tight throat, general 'wobbliness'
and pain in the abdomen. With all that, it is not difficult to understand
why somebody who hyperventilates is usually in a semi-permanent state of alarm
about their body.

There are a number of methods which can be used to reduce the effects of hyperventilating
fairly quickly. One often recommended is to place a paper bag over the
nose and mouth and to breath into it, thus inhaling extra carbon dioxide which
quickly retrieves the blood chemistry balance. However, if somebody feels that
they are gasping for air, further restricting its passage into the lungs is
unlikely to be welcomed. There are also the additional problems of making
shaky hands find the bag, inevitably folded small somewhere, and of withstanding
the startled looks of people walking past as the exercise is undertaken.
(Of course, thinking about this might take the person's mind off the attack
and so be an aid to recovery).

Other methods suggested have been: using cupped hands instead of a bag.
Slowing breathing down as with "In.. one.. two.. three.. Out.. one..
two.. three". (Ensuring that 'slower' doesn't
mean 'much deeper' or the good work can be undone), Trying
to avoid 'gulping air' if there is a strong feeling of breathlessness.
(Swallowing a couple of times helps here or holding the gulp for a few seconds
if it cannot be avoided, and then letting the air out slowly). Running, and
doing knee squats. Both of the latter physical responses seem to be
good ways to retrieve the sagging carbon dioxide 'pressure' and
may be readily undertaken by those who experience a driving need for action/escape
at such times.

Running away, if the hyperventilating is part of panic in reaction to anxiety
problems, is one of the prime things people are urged not to do. However,
if it reduces the attack and the sufferer is aware that returning to the phobic
situation as quickly as possible afterwards is essential, then it can be an
option.

The panicking person will want to 'escape' from the situation
they are in. If you, as a helper can, try to persuade him or her not to. Running
away may seem to bring relief, but it will make the situation much harder to
bear next time and will reinforce the belief that the situation was dangerous
and that escape is the best way to deal with it. Both of these responses
lead to chronic habit. Try to negotiate a small delay: "You can hang
on for one more minute ... just count to 60 and then we'll go". But don't
bully, agoraphobic people have to make their own choices.